Case Scenarios for Lecture Discussion

Hey everybody. Hope clinicals are going smoothly for everyone. Anyway, Mrs. Semillo has put up an assignment for lecture on Thursday.  I am not aware of how it will utlized during lecture if at all, so I am also unaware of whether it will be checked.  If anything, complete as much of it as you can. If there are some you are stuck on, consult a fellow student or be ready to ask about it on Thursday.

If you want the link to the file, HERE it is.  Just we aware that it is in docx file format, and you may be unable to open it if you do not have the proper software.

Nursing Care of the Patient with Hepatitis A

 

Scenario:

 

P.M., a 24-year-old house painter, has been too ill to work for the last 3 days.  When he arrives the ED, he seems an alert but acutely ill young man of average build, with a deep tan over exposed areas of skin.  He reports headaches, severe myalgia, a low grade fever, cough, anorexia, and N&V, especially after eating any fatty food.  P.M. describes vague abdominal pain that started about the same time as other problems. 

 

PMH: no health problems, nonsmoker, drinks a "few" beers each evening to relax. 

 

Physical Assessment:   VS-BP-128/84; 38.1º(C)-88-26. 

                                    A&O x 3, MAE well except for aching pain in his muscles;

                                    Very slight scleral jaundice present; PERRL

                                    Cardiac-Distinct S1, S2, HRRR

                                    Lungs-CTA anteriorly and posteriorly

                                    GI/GU-Abd soft; moderate hepatomegaly noted; liver edge easily palpated and                                                   tender to palpation.  Pt. mentions that his urine has been getting darker over                                                  the last 2 days.

 

Labs:                            Na+                  140 mmol/L                 (135-145 mmol/L)

                                    K+                    3.9 mmol/L                  (3.5-5.5 mmol/L)

                                    Cl                     102 mmol/L                 (98-106 mmol/L)

                                    BUN                 10 mg/L                       (10-20 mg/L)

                                    Cr                    3.8 g/dL                       (0.5-1.2 mg/dL)

                                    Tot. Protein    6.2 g/dL                       (6.4-8.3 g/dL)                        

                                    ALT (SGPT)      66 U/L                         (5-36 U/L)                  

                                    AST (SGOT)      52 U/L                         (0-35 U/L)

                                    LDH                  205 U/L                        (100-190 U/L) 

                                    ALP                  176 U/L                        (30-12 U/L)

                                    PT                    12sec/INR = 1.06          (11.0-12.5 sec)           

                                    PTT                  32 sec                          (60-70 sec)

                       

                                    Urobiligen       1.6 µmol/day               (0.8-6.8 µmol/day)

                                    Protein                        +                                  (Negative)

                                    Bilirubin           +                                  (Negative)

                                   

                                    Hepatitis Panel pending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTIONS:

 

1.         Which key diagnostic tests will determine exactly what type of hepatitis is present?  (k)

 

2.         An Chemistry Panel was drawn.  Which of the labs listed above specifically indicates liver     disease?           (k)

 

3.         List 8 or more drugs that can cause increased ALT (SGOT) levels.  (k)

 

4.         Considering that the basic pathology of hepatitis involves inflammation, degeneration, and      regeneration of the hepatocyte, what type of diet will you strongly encourage P.M. to follow?      (k)

 

5.         Differentiate between Hepatitis A, B and C on the basis of mode of transmission.  (k)

 

6.         Name three activities that can be done in the community to prevent the spread of hepatitis          (and any/all types).  (c)

 

7.         In P.M's case, the IgM-class anti-HAV antibody is positive.  This indicates that P.M. is infected          with Hepatitis A and is the acute or early convalescent period of the disease.  Is this disease contagious.     What precautions would you take?  (c)

 

8.         Pruritis is usually associated with jaundice.  What will you do to ease this problem for P.M.?  (app)

 

9.         How would you explain to P.M. the likely progression of his disease?  (requires only knowledge       of disease and progression but figuring out his thought processes).  (an)

 

10.       P.M. is living at home with his parents and 8 younger siblings.  The youngest is a 4-year-old.         His parents ask how to prevent the rest of the family from getting hepatitis.  What specific instructions will you give?  How will you know that these instructions are understood?  (an)

 

11.       Given P.M.'s lifestyle, what specific patient teaching points must you emphasize?  (ap)

 

12.       List four critical issues relevant to P.M's nursing care.  (an)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Care of the Patient with Acute Pancreatitis

 

Scenario:

 

B.B., a 72-year-old woman, is admitted from the ED with c/o constant, severe abdominal pain and lower back pain x 2 days and SOB over the last 24 hours.  "I've had to rest 4 or 5 times gettin' back to the house from the shed.  It's gotten real hard to manage all by myself."  A niece stopped by and insisted B.B. come into the county hospital ED.  B.B. has never received any medical care of any kind.  She lives by herself "up the mountain" off a dirt road in rural Pennsylvania.  She is restless, nauseated and in pain.  Everything around her in the hospital is new and frightening to her.  VS are 37.9º(C) (tympanic)-128-30; BP 108/72.  SaO₂-84% on 2 L O₂/nc.  B.B. is admitted to your unit at 1900.

 

QUESTION:

 

1.         Based upon the presentation of severe abdominal pain, what are possible medical problems?        (ap)

 

2.         The ED nurse is giving you report says the B.B.'s admitting diagnosis is R/O pancreatitis.  You        know that pain control is difficult in patients with pancreatitis.  What information will you    want to ask the ED nurse before hanging up?  (c)     

 

3.         B.B. arrives on your unit.  As she is getting into bed, you notice that her eyes are very wide and she is looking all around.  She seems totally overwhelmed in response to the ED nurse's        instructions about how to operate the bed.  What kind of information may be used to guide the        manner in which you approach B.B.?  (an)

 

4.         What approach would you used to obtain a psychosocial history and complete your assessment?     (ap)

 

You complete an assessment and not the following abnormalities: restlessness, prefers to sit on side of bed, leaning forward and tightly clutching her handbag.  States pain has decreased "some after that lady jabbed me with that needle downstairs."  Skin cool, diaphoretic, and pale.  Heart rate irregular and tachy.  Peripheral pulses weakly palpable x 4 extremities.  Respirations rapid but unlabored on 2 L O₂/nc, SaO₂ 85%, breath sounds absent at the base on the LLL (left lower lobe) posteriorly.  Reports marked nausea without emesis.  BS hypoactive x 4.  Abdomen distended and exquisitely tender throughout to light palpation, guarding noted.  Has not voided but states that she has "made less water than usual".  Poor skin turgor, dry mucous membranes, mild scleral jaundice.

 

QUESTION:

 

5.         How are you going to assess B.B.'s pain?  (app)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.B.'s admission labs return:

 

Na+                  148 mmol/L                                                     Lipase              375 U/L

Cl                     114 mmol/L                                                     LDH                  160 U/L

K+                    4.2 mmol/L                                                      AST                  54 U/L

HCO3               98 mmol/L                                                       ALT                  46 U/L

BUN                 26 mg/dL                                                         ALP                  96 U/L

Cr                    1.0 mg/dL                                                        Amylase           200 U/L

Glucose           185 mg/dL

 

Hg                    12.5 g/dL

Hct                  38%

Plt                    306 cmm

 

6.         Indicate which lab values are important in the diagnosis of pancreatitis.  (k)

 

7.         Review the Hemogram and Chemistry Panel.  What results are consistent with your             observations on her physical exam?  (an)

 

8.         B.B voids 150 mL dark brown urine 2 hours after admission to your unit.  What will you do?

 

9.         The physician orders a 500 mL bolus of NS, a foley to be inserted and an NG tube to be        inserted.  What do these orders mean, and why are they appropriate at this time?  What    priority assessment must be done when a fluid bolus is given?  (ap)

 

10.       What is the purpose of inserting an NG tube?

 

11.       What is your responsibility regarding the monitoring and maintaining the NG tube?

 

You deliver the NS bolus over an hour and insert a foley catheter.  You are surprised that the color of B.B.'s urine is dark amber, instead of the dark brown urine you saw in the commode.  You send the specimen to the lab. 

 

12.       The next time you answer B.B's call light, she states that her pain is "Getting bad again".  You     are puzzled because she is not used to taking narcotics and it has only 2 hours since her last   injection of morphine 5 mg.  What can be done to improve her pain management?  (c)

 

NSAIDs are added to the pain regimen.  You administer the first dose and notice that her bedpan is under the covers and contains the same dark urine fluid that you noted in the commode.  You ask B.B. about it and she states, "Aw honey, that's just my chewing tobacco."  She spits, and the dark fluid lands in the pan. 

 

13.       Is there any connection between heavy tobacco use and the effectiveness of medications?  (c)

 

14.       Based upon your discovery, what action would you take?  (ap)

 

15.       B.B.'s oximeter alarms at 83%, her respiratory rate is 34, and the IV bolus has infused.  You      auscultate with no breath sounds from the scapula down on the left.  What is the significance     of your findings?  (an)

 

16.       What two actions would you take next and why?  (app)

 

The physician orders a STAT CXR, which shows a pleural effusion developing over the LLL. 

 

17.       Based upon the diagnosis of pleural effusion, what treatment will the physician likely perform           next, and what is your responsibility throughout the treatment?

 

 

 

Patients with sub-diaphragmatic inflammatory processes frequently present with pneumonia or pleural effusion.  Cloudy, yellow fluid (250 mL) was removed.  B.B. was placed on broad spectrum antibiotics until cultures returned.  She was found to have acute pancreatitis and was eventually released to home.  As she is wheeled out of the hospital, B.B. tells you, "I'll die up on my mountain before I'll come back here."  She probably did.